3 Breaking Bad NewsWe are required to communicate bad news to patients, family members, and caregiversMethod is importantShapes the course of subsequent grief and copingStrengthens trustFosters collaboration in planningIn the ED, often sudden and unexpected

5 Is this important?Bad news, conveyed in an inappropriate, incomplete, or uncaring manner may have long-lasting psychological effects on the family*“Give necessary orders with cheerfulness and serenity...revealing nothing of the patient's future or present condition”- Hippocrates§§Hippocrates. Decorum, XVI. In: Jones WH, Hippocrates with an English Translation. Vol 2. London: Heinemann, 1923.*Parkes CM. BMJ 1964;2:

6 BBN – What they want Privacy when receiving newsThe ability to express emotions safelyInformation free of unclear language or medical jargonEmpathetic and caring attitudeAllowance for hopeAbility to ask and receive good medical informationRosen

7 BBN – Some key points Listen Pause Be guided by the patient and familyPace, amount of information, style“It's a solemn ceremony to preside over a death and a grim one to announce it, a morbid unveiling, a confirmation.”Neilson. Can J Emerg Med 2007;9(5):389

9 BBN – SPIKES approach Setup: PreparationPerception: What does the family know?Invitation: How much do they want to know?Knowledge: Sharing the informationEmotions/Empathy: Responding to feelingsSummary/Strategy: Planning & F/UThe Oncologist 2000;5:

11 Step 2: Perception What does the patient/family know?Were they with pt prior to ED arrival?What have they been told so far?Can help adjust the way you deliver bad newsDon’t prolong this partPerceived as delaying74% prefer immediate notification of death**EM Reports 2005;26(7)

12 Step 3: Invitation How much do they want to know?Cultural differencesSometimes age-dependent

14 Step 4: Knowledge Sharing the informationMay want to explain EMS/ED details of careEnsure family that their response was appropriateEnsure family that pt did not experience unnecessary sufferingOffer viewing of deceasedSome warningsMore family members regret not viewing than viewing the body*Organ/tissue donation conversation±Autopsy/MESurvivor guilt is likely the only aspect of the grief response that EP’s can alterWarnings – tubes, lines, colour/temp changesTissues (corneas, eyes, skin, bone, veins, and heart valves ) that are ischemia resistant can be retrieved 10-24h after death (if body refridgerated within 4hrs of death)Organ donation – pts >80, HIV, severe HTN not eligible*Parish et al. Annals of EM. 1987:16;1792

15 Step 5: Emotions/Empathy Responding to feelingsVariety of responses (sadness, rage, blame, etc)Allow them to express this responseSW, Chaplain can help

17 BBN – SPIKES approach Setup: PreparationPerception: What does the family know?Invitation: How much do they want to know?Knowledge: Sharing the informationEmotions/Empathy: Responding to feelingsSummary/Strategy: Planning & F/UAnyone use a different approach? Anything to add to any of the steps that works for you?

18 Complaints Not being kept informedNot speaking with a physician (or not realizing they had)Being unclear of the details of care by EMS/EDPatient belongings being handled improperlyParrish et al. Annals EM 1987;16:792

21 Family presence at resuscitation94% of families said they would participate again76% felt this facilitated their adjustment to death64% felt their presence helped the deceased80% who were not present wanted to be96% believe they have the right to be presentEM Reports 2005;26(7)

22 Family presence at resuscitationUp to 30% of staff members report increased stressWhat experience have you had with this?Tsai E. NEJM. 2002;346:1019